Elsevier

General Hospital Psychiatry

Volume 31, Issue 2, March–April 2009, Pages 103-109
General Hospital Psychiatry

Psychiatric–Medical Comorbidity
Inpatient suicide: preventing a common sentinel event,

https://doi.org/10.1016/j.genhosppsych.2008.09.007Get rights and content

Abstract

Objective

Suicide in the hospital is one of the most common types of sentinel events, and hospitals can (and should) take steps to decrease the likelihood of experiencing this type of crisis.

Method

MEDLINE, Cochrane Library, National Electronic Library for Mental Health, and PSYCHINFO searches were conducted. In addition, manual and phone queries were used to identify relevant empirical and clinical publications. Reference sections of published articles were also searched.

Results

The current article discusses the rates of suicide in hospitals, related risk factors, methods of suicidal behavior, and factors which contribute to this tragic event. Environmental, patient care, staff training, and hospital policy recommendations for decreasing the number of inpatient suicides are presented.

Conclusion

Inpatient suicide is a traumatic event. Although it is a relatively rare occurrence that is often difficult to predict and prevent, continuing to refine our efforts to assist the population at risk is imperative.

Introduction

In order to promote patient safety, there is an increasing push toward transparency with regard to patient outcome data in the United States medical system. The impetus for this movement was sparked largely in the 1990s when two prominent reports summarizing the number and type of errors committed by hospitals were published [1], [2]. These reports discussed adverse events, also referred to as reportable occurrences, or sentinel events, which are incidents that result from errors or equipment failures “involving death or serious physical or psychological injury, or the risk thereof… that require immediate investigation and response” [3]. For instance, wrong site surgery, medication errors, hospital-acquired infections, operating room fires, serious injuries, accidental deaths, murder, abduction and suicide all fit under the umbrella of sentinel events.

Historically, and currently, patient suicide in the hospital has been one of the most frequently reported sentinel events. Even though all inpatient suicide is not preventable, hospitals and clinicians need to work together to develop clear protocols for risk assessment and safety precautions. Unfortunately, this task is hampered by a relative lack of scientific information for guidance. The literature base investigating inpatient suicide is relatively small, and many of the studies are not current. There is also a paucity of studies specifically focused on suicide in general medical/surgical units, so recommendations for how to decrease these events in such settings are often based on information collected from other populations [4], [5].

In addition, even though national organizations such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Department of Veterans Affairs monitor the number of sentinel events in hospitals, reporting is primarily voluntary and limited to hospitals who are certified by the relevant organization (for example, a hospital that is not certified by JCAHO would not participate in their reporting system). Only 20 states have mandatory sentinel event reporting systems in place [6]. As a result, some hospitals may not be reporting inpatient suicide, and instead, addressing the event internally [7], [8]. Relatively low reporting rates suggest that these systems are not capturing all of these relevant data [6]. As of June 30, 2007, only 65.6% of the JCAHO sentinel events were self-reported [9].

The current article is designed to examine what is known about the rates of inpatient suicide, related risk factors, methods of suicidal behavior, and factors which contribute to this tragic event. The article ends with environmental, patient care, staff training, and hospital policy recommendations for decreasing the number of inpatient suicides. For this article, MEDLINE, Cochrane Library, National Electronic Library for Mental Health and PSYCHINFO searches as well as manual and phone queries to identify relevant empirical and clinical publications were conducted. Reference sections of published articles were also searched.

Section snippets

Prevalence

Bearing in mind the aforementioned problems (the lack of a national mandatory reporting system, and the low rates of self-reporting), available data suggest that inpatient suicide is a relatively frequent sentinel event. 16.3% of the sentinel events voluntarily reported to JCAHO between January 1995 and January 2005 were inpatient suicides, making it most common type of adverse event during this period [9]. The most recent JCAHO data (from January 1995 to June 30, 2007) suggests that inpatient

Contributing factors

Hospitals in the United States who report a sentinel event to the JCAHO must gather information about the causes of the incident (referred to as a “root cause analysis”[7], [8]. A root cause analysis examines the current process in place for handling these types of situations, as well as what happened during the particular circumstance [14]. According to JCAHO, from 1995 through 2005, the three most common factors related to inpatient suicide were environmental safety failures, problems with

Common methods for inpatient suicide

In 75% of the inpatient suicides reported to JCAHO between January 1995 and January 2005, the method was a hanging in a bathroom, bedroom or closet. Twenty percent of the suicides resulted from patients jumping from a roof or window [3]. Empirical investigations support these data; hanging and jumping were the most frequent suicide methods among general hospital patients, patients in psychiatric wards and patients in psychiatric facilities [4], [5], [11], [12], [15], [17], [20], [21], [22], [23]

Risk factors/characteristics

Inpatients are a unique population group. Therefore, risk factors for suicidality in this group are not necessarily the same as those for other groups [33]. As a result, using risk factors/characteristics from community samples to predict who will attempt and commit suicide while in the hospital will yield many false positives [15].

Some authors suggest that, due to methodological problems, relying on risk factors/predictors taken from previous studies (rather than focusing on a patient's

Suicide risk factors in inpatient psychiatry units or psychiatric hospitals

With those preceding caveats in mind, it is possible to construct a profile of the person who tends to commits suicide in a psychiatric unit or psychiatric hospital: a young, single male [12], [20], [24], [32], [35], [36], [37]. Common diagnoses include depression, schizophrenia, personality disorders, dual diagnoses, and/or psychotic symptoms [12], [20], [23], [24], [31], [32], [35], [36], [37], [38], [39], [40], [41], [42], [43]. Admission was often prompted by a suicide attempt, and/or the

Suicide risk factors in general hospital units

Patients who commit suicide on general hospital (i.e., medical/surgical) units seem to have a different profile than patients from psychiatric units or those who commit suicide in the community. Again, traditional risk factors may not be a useful barometer for predicting a particular patient's level of risk. For example, general hospital patients who commit suicide are less likely to have a known history of psychiatric illness or suicidal behavior [5].

Patients at risk on general hospital units

Recommendations for addressing suicidal behavior in the hospital

There is not one solution to decreasing the potential for inpatient suicide. A comprehensive suicide risk reduction plan must take into account the unique features of a particular hospital and a particular unit. Modifying staffing levels, staff training and communication, the physical environment, the process of patient assessment and care and unit/hospital policies and procedures is critically important. Recommendations are provided in each of these domains in Fig. 1, Fig. 2, Fig. 3, Fig. 4,

Conclusion

Inpatient suicide is a traumatic event for everyone involved. It can be particularly devastating for internists, psychiatrists or general physicians if their patient (sometimes of many years) commits suicide. Even though it is a relatively rare occurrence that is difficult to predict and prevent, continuing to refine our efforts to assist the population at risk is imperative [12]. The changes we have suggested in this article may not be easy to implement; increasing focus on prevention (i.e.,

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    Supported in part by Grant 24768 from the Ohio Health Foundation, Columbus, OH.

    The Psychiatric–Medical Comorbidity section will focus on the prevalence and impact of psychiatric disorders in patients with chronic medical illness as well as the prevalence and impact of medical disorders in patients with chronic psychiatric illness.

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